Healthcare Provider Details

I. General information

NPI: 1245645100
Provider Name (Legal Business Name): MARISSA BINGHAM M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 HERMOSA DR SE
ALBUQUERQUE NM
87108-4312
US

IV. Provider business mailing address

31 SIERRA ROSA
SANTA FE NM
87507-7602
US

V. Phone/Fax

Practice location:
  • Phone: 505-237-0061
  • Fax: 505-237-0068
Mailing address:
  • Phone: 541-870-9374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT-0177501
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: